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Download Debit Order Form - BANK DEBIT ORDER INSTRUCTION CREDIT .doc

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									BANK DEBIT ORDER INSTRUCTION / CREDIT CARD AUTHORITY


 E-PAYMENTS for Equadoor                                                          CK 2001/016090/23        / VAT NO. 4000148421
 P O BOX 49275, Qualbert, 4078



  Name (Debtor)                                                        Date
  Postal Address                                                       Tel No. (land & cell)
                                                                       Debit Amount               R _________ (Excl. Vat)
 Physical Address                                                      Domain Name


 I.D. Number                                                           Vat No. (if applicable)
 Email Address :
 The details of my/our account are as follows:
 BANK                                                                  CARDHOLDERS NAME
 BRANCH TOWN                                                           CARD NUMBER
 BRANCH NO. :                                                          EXPIRY DATE
 ACCOUNT
                                                                       CVV NUMBER
 NAME.
                                                                                                  (three digit number on back of
 ACCOUNT NO.
                                                                                                  card)
 TYPE OF A/C          (savings,current, transmission)                  CARD TYPE                  (master card, visa)
 I/we hereby request and authorize you to draw against my/our account with the abovementioned bank (or any other bank or
 branch to which I/we may transfer my/our account) the sum of _________________________(state amount in words) or any
 variable amount pertaining to this agreement, on the first working day of each month. This being the amount necessary for the
 settlement of the monthly due to you in respect of our purchases/contract/agreement dated
 _________/_________/_________.
 All such withdrawals from my/our account by you shall be treated as though they had been signed by me/us personally.
 I/we the undersigned, "instruct" and authorize your agent Netcash (Pty) Ltd, to draw against my/our account. I/we understand
 that if bank details have been supplied the withdrawals authorized here will be processed by BankServ. I/we also understand
 that details of each withdrawal will be printed on my/our statement.
 I/we agree to pay any banking charges and E-Payments charges relating to this debit order instruction
 This authority may be cancelled by means of giving you thirty days notice in writing, sent by prepaid registered post, but I/we
 understand that I/we shall not be entitled to any refund of amounts, which you have withdrawn whilst this authority was in force
 if such amounts were legally owing to you.
 Assignment:
 I/We acknowledge that the party hereby authorized to effect the drawing(s) against my/our account may not cede or assign
 any of its rights and that I/we may not delegate any of my/our obligations in terms of this contract/authority to any third party
 without prior written consent of the authorized party.
 Signed at _________________ on this _________________ day of _________________ 200__


 SIGNATURE AS USED FOR SIGNING CHEQUES OR CREDIT CARD VOUCHERS                                          [Fax to: 086 687 0932]

								
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